Clean Claim Acceptance Rate in Ophthalmology: Is Your Practice’s Too Low?

By Michael Carroll on August 22, 2016

There are a lot of reasons (and excuses) for a low clean claim acceptance rate. Health care reform, ICD-10 conversion, the transition to electronic health records, as well as patients changing insurance carriers all play a role in creating a challenging environment. It’s been a rough five years for health care, and billing bears most of the burden. Simply put, a clean claim is a claim that is processed and reimbursed the first time it’s submitted to a payer. Ideally, your clean claim acceptance rate should be 95 percent or above. That’s easier said that done, however. A recent survey of medical practices in the US found that 35 percent have rates that fall between 70 and 80 percent.

Why Worry About Your Low Clean Claim Rate?

Seventy or 80 percent is pretty high, and the money eventually comes in, right? The above survey reported 45 percent of offices have two to five people working on denial resolution at some point in their day. That is a lot of wasted staff working on re-processing claims. While not all denials are the provider’s fault, often times the denial occurs because of failure to submit a clean claim. Common errors include a misspelled name, wrong birth date, non-covered services or services that required pre-authorization, expired insurance, or the office simply did not submit a clean claim in the allotted time.

Every time an “unclean” claim is submitted, the practice loses valuable staff time and runs the risk of not collecting at all. Consider this. According to the Healthcare Billing and Management Association (HBMA), 30 percent of Medicare and Medicaid claims are denied on the first submission, and 60 percent of those claims are never resubmitted. The HMBA commented, “Proper coding and clinical documentation can make or break an otherwise well-run practice.”

Even if you meticulously resubmitted every denial, NueMD puts the cost of resubmission at $25 per claim, and that’s a conservative estimate. That means, if you are a small office that sees 20 patients in one day, and your clean claim acceptance rate is only 70 percent, you are resubmitting roughly 30 percent. That would be six claims per day at $25 each. The office would be losing $150 per day or nearly $40,000 per year if we only count weekdays. Now imagine that number growing exponentially in larger practices with multiple providers that might see over 100 patients per day.

The bottom line is a healthy revenue management cycle depends on efficient billing and collections, and a low clean claim rate works against a healthy cycle. Do you know your clean claim acceptance rate?

Best Practices For Your Ophthalmology Practice To Achieve 95% or Higher Clean Claim Rate

Calculating your clean claim rate is fairly easy. You most likely use a billing system that can generate a report for you. The simple calculation is percent of clean claims divided by the total number of claims. Your goal should be 95 percent or higher. Here are a five tips to get you there.

  1. Understand the rules. Don’t take a trial and error approach. Our health care system is a dynamic one. Rules are constantly changing. For example, many health care services are now bundled, only requiring one claim. However, continuing to file multiple claims will result in denials since the payer views them as duplicates. A simple mistake can result in late payments, missed deadlines and wasted staff time. Practices must have someone, or a trusted outside vendor, to take a proactive approach to research and discovery. This ensures the office is up-to-date on each payers’ rules.
  2. Closely monitor denials. Learn from mistakes. Analyze regular reports that identify the causes for denied claims. Categorize denials and look for the root cause. Don’t pass things off as human error. Find out why a patient’s name was misspelled and no one caught it before the claim left the building. Why didn’t the office have the most recent insurance information? Implement a process to prevent the most common errors found during the reporting process. Organize reports based on payers, so you can easily identify trending issues with that particular insurer.
  3. Partner with a “claims scrubber.” Establish a relationship with a vendor that is able to find even vague payer rules, and can customize pre-billing edits for your practice. Keep in mind that claims scrubbers specialize in staying current with payer rules, which is important. However, denials based on simple records errors still fall on the practice to identify and prevent.
  4. Develop a culture of accountability. This doesn’t mean you call out every employee that made an error on a claim. Modern Medicine says “Rally, (don’t punish) your team.” Instead, develop a culture where everyone knows the importance of their role in the clean claims process. From the front desk staff that greets the patient and verifies their information, to the physician that correctly notes the services rendered so the medical coder gets the coding right, all the way to the AR staff that submits the claim, each person plays a role. Develop goals, benchmarks and rewards around your clean claim acceptance and denials rates.
  5. Have a well-documented process. To achieve the accountability described above, a well-documented process must detail each staff members’ role. This will enable you to easily find vulnerabilities and fix them.

Utilizing Best Practices is Critical to Your Ophthalmology Practice!

An effective billing and collections is critical to running a profitable office. It’s the bond that unites the business and clinical sides of your practice. Medical Economics put it well when its authors said, “Find inefficiencies and stop them.” Let Agnite Health help your practice stop inefficiencies and get back lost revenue. Our goal is to have a 99 percent acceptance rate on the first submission of your claims. Contact us to get started.